Breaking the Risk-Outcome Dogma in Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative

<b>Background:</b> The American Society of Anesthesiologists (ASA) Physical Status classification is widely used as a proxy for perioperative risk, yet its relationship to contemporary ventral hernia repair (VHR) case mix and patient-centered outcomes remains incompletely defined.MethodsWe performed an unadjusted retrospective cohort study of adult VHRs in the Abdominal Core Health Quality Collaborative, comparing ASA I-II versus ASA III-IV patients. Analyses emphasized clinically interpretable effect sizes (Cohen's d and h) with conventional <i>P</i> values reported for completeness.ResultsWe analyzed 28,779 ASA I-II and 26,436 ASA III-IV repairs. ASA III-IV patients were older (60.65 ± 12.42 vs 52.38 ± 13.92 years; d = 0.63), had higher BMI (33.52 ± 7.41 vs 30.19 ± 5.83 kg/m²; d = 0.50), and greater comorbidity burden (hypertension 61.2% vs 30.9%; h = 0.62). Hernias were larger in ASA III-IV patients (width 7.91 ± 6.59 vs 3.93 ± 4.07 cm; d = 0.73), and operative complexity markers were higher, including dirty/infected wounds (2.1% vs 0.6%; h = 0.14) and longer operations (≥240 min: 21.0% vs 7.4%; h = 0.40). ASA III-IV patients had longer length of stay (3.72 ± 12.06 vs 1.44 ± 12.14 days; d = 0.19) and higher 30-day mortality (0.361% vs 0.035%; OR = 10.42). Among cases with non-missing 1-year outcome fields, 1-year recurrence (12.1% vs 10.4%; <i>P</i> = .10) and 1-year reoperation (7.0% vs 7.1%; <i>P</i> = .86) were similar. Higher-risk patients demonstrated greater 6-month quality-of-life improvement (ΔHerQLes 29.99 ± 30.35 vs 24.40 ± 28.45; d = 0.19).DiscussionAlthough ASA class stratifies physiological risk and complexity, it does not imply diminished reconstructive benefit, supporting individualized, risk-informed decision-making rather than exclusion based on ASA status alone.